SUBMITTED TO

MRS. MANILA
ASSOCIATE PROFESSOR
PRESENTED BY
MS.NISHA KAUSHIK
MSC NURSING 1ST YEAR

INTRODUCTION
Shock is a condition in which cardiovascular system fails to perfuse
tissues adequately.
An impaired cardiac pump , circulatory system, and/or volume can
lead to compromised blood flow to tissues.

SHOCK
Inadequate tissue perfusion can result in :
Generalized cellular hypoxia (starvation)
Widespread impairment of cellular metabolism
Tissue damage Organ failure
Death
DEFINITION
Shock is a life threatening medical condition as a result of insufficient blood
flow throughout the body.
OR
Shock is a medical emergency in which the organs and tissues of the body are
not receiving an adequate flow of blood.
Inadequate perfusion and oxygenation of cells leads to:
Cellular dysfunction and damage
Organ dysfunction and damage

ETIOLOGY
Heart conditions-heart attack ,heart failure
Heavy internal or external bleeding, such as from a serious injury or
rupture of a blood vessel
Dehydration, especially when severe or related to heat illness.
Infection (septic shock)
Severe allergic reaction (anaphylactic shock)
Spinal injuries (neurogenic shock)
Burns
Persistent vomiting
PATHOPHYSIOLOGY OF SHOCK
Impaired tissue perfusion occurs when an imbalance develops
between cellular oxygen supply and cellular oxygen demand.

All types of shock eventually result in impaired tissue perfusion and
the development of acute circulatory failure or shock syndrome.
CELLS SWITCH FROM AEROBIC TO ANAEROBIC METABOLISM
LACTIC ACID PRODUCTION
CELL FUNCTION CEASES AND
SWELLS
MEMBRANE BECOMES MORE PERMEABLE
ELECTROLYTES AND FLUIDS SEEP IN & OUT OF CELL
Na+/k+ PUMP IMPAIRED
MITOCHONDRIA DAMAGE CELL DEATH
PATHOPHYSIOLOGY
CLINICAL PRESENTATION :GENERALIZED
SHOCK
VITAL SIGNS
Hypotensive < 90 mm Hg
MAP < 60 mm Hg
Tachycardia :weak and Thready pulse
Tachypneic :blow off CO2 Respiratory alkalosis
MENTAL STATUS
Restless ,irritable ,apprehensive unresponsive
DECREASED URINE OUTPUT

SHOCK SYNDROME
HYPOVOLEMIC SHOCK
Blood volume problem
CARDIOGENIC SHOCK
Blood pump problem
DISTRIBUTIVE SHOCK
(septic ;anaphylactic ;neurogenic)
Blood vessel problem
HYPOVOLEMIC SHOCK
Loss of circulating volume Empty tank decrease tissue perfusion
general shock response
ETIOLOGY :
Internal or external fluid loss
Intracellular and extracellular compartments
Most common causes:
Hemorrhage
Dehydration


EXTERNAL LOSS OF FLUID
Fluid loss: Dehydration
Nausea and vomiting , diarrhea ,massive diuresis , extensive burns.
Blood loss :
Trauma : blunt and penetrating
BLOOD YOU SEE
BLOOD YOU DONT SEE

INTERNAL LOSS OF FLUID
Loss of Intravascular integrity

Increased capillary membrane permeability

Decreased colloidal osmotic pressure (third spacing)


PATHOPHYSIOLOGY OF HYPOVOLEMIC
SHOCK
DECREASED
BLOOD
VOLUME
DECREASED
VENOUS
RETURN
DECREASED
STROKE
VOLUME
DECREASED
CARDIAC
OUTPUT
DECREASED
TISSUE
PERFUSION
CLINICAL PRESENTATION
Tachycardia and tachypnea
Weak and rapid pulses
Hypotension
Skin cool & clammy
Mental status changes
Decreased urine output ; dark & concentrated

INITIAL MANAGEMENT
MANAGEMENT GOAL: Restore circulating volume ,tissue perfusion ,&
correct cause
Early recognition Do not relay on BP (30% fluid loss)
Control hemorrhage
Restore circulating volume
Optimize oxygen delivery
Vasoconstrictor if BP still low after volume loading

MEDICAL MANAGEMENT
TREATMENT OF THE UNDERLYING CAUSES
If the patient is hemorrhaging ,efforts are made to stop bleeding .this may
involve applying pressure to the bleeding site.
If the cause of hypovolemic shock is diarrhea or vomiting , medications
to treat diarrhea or vomiting are administered.
FLUID AND BLOOD REPLACEMENT
Deliver a minimum of 20 Ml/Kg of crystalloid.



FLUID REPLACEMENT IN SHOCK
FLUIDS ADVANTAGES DISADVANTAGES
CRYSTALLOIDS
0.9% sodium chloride Widely available
,inexpensive
Require large volume of
infusion;can Cause hypernatremia,
pulmonary edema ,abdominal
compartment syndrome.
Lactated Ringers Lactate ion helps buffer
metabolic acidosis

Require large volume of
infusion;can Cause hypernatremia,
pulmonary edema ,abdominal
compartment syndrome.

Hypertonic Saline Small volume needed to
restore intravascular
volume
Danger of hypernatremia and
cardiovascular compromise from
rapid fluid shifts
COLLOIDS
Albumin(5% ,25%) Rapidly expands plasma
volume
Expensive ,require human donors
Dextran Synthetic plasma
expander
Interferes with platelet aggregation
,not recommended for hemorrhagic
shock
Hetastarch Synthetic plasma
expander

Prolonged bleeding and clotting
time
FLUIDS ADVANTAGES
DISADVANTAGES

CRYSTALLOIDS
0.9% NORMAL SALINE
SOLUTION
Widely available
,inexpensive
Requires large volume of infusion can
cause hypernatremia , pulmonary
edema ,abdominal compartment
LACTATED RINGER S Lactate ion helps buffer
metabolic acidosis
Requires large volume of infusion can
cause hypernatremia , pulmonary
edema ,abdominal compartment

HYPERTONIC SALINE
(3%)
Small volume needed to
restore intravascular
volume
Danger of hypernatremia and
cardiovascular compromise from rapid
fluid shifts
COLLOIDS
ALBUMIN Rapidly expands
plasma volume
expanders
Expensive ;requires human donors
;limited supply ;can cause heart
failure
DEXTRAN Synthetic plasma
expanders
Not recommended for hemorrhagic
shock
REDISTRIBUTION OF FLUID
A modified Trendelenburg position is recommended for proper
redistribution of fluids.
A full Trendelenburg position makes breathing difficult and does not
increase BP or cardiac output.
PHARMACOLOGIC THERAPY
If fluid administration fails to reverse hypovolemic shock ,then vasoactive
medications that prevent cardiac output are given.
Medications are also administered to reverse the cause of dehydration .For
ex-desmopressin (DDAVP) is administered for diabetes insipidus.



NURSING MANAGEMENT
ADMINISTERED BLOOD AND FLUIDS SAFELY
Administering blood transfusions safely is a vital nursing role .
In emergency situations , it is important to acquire blood specimens quickly,
to obtain a baseline complete blood count , and to type and cross match the
blood in anticipation of blood transfusions.
A patient who receives a transfusion of blood products must be monitored
closely for adverse effects.
Fluid replacement complications can occur ,often when large volumes are
administered rapidly.
Nurse monitors the patient closely for cardiovascular overload ,signs of
difficulty breathing and pulmonary edema.
Temperature should be monitored closely to ensure that rapid fluid
resuscitation does not cause hypothermia .
IV fluids need to be warmed during the administration of large volumes.

CARDIOGENIC SHOCK
The impaired ability of the heart to pump blood.
Pump failure of the right or left ventricle.
Most common cause is LV MI (Anterior)
Occurs when >40% of ventricular mass damage
Mortality rate of 80% or more.
ETIOLOGIES
MECHANICAL
COMPLICATIONS OF MI
OTHER CAUSES
Papillary muscle rupture cardiomyopathies
Ventricular aneurysm Tamponade
Ventricular septal rupture Tension pneumo thorax
Arrhythmias
Valve disease
PATHOPHYSIOLOGY
Decrease
cardiac
contractility
Decrease
stroke volume
and cardiac
output
Pulmonary
congestion
Decreased
Systemic
Tissue
perfusion
Decreased
coronary
Artery
perfusion
CLINICAL PRESENTATION
Patients experience the pain of angina
Dysrhythmias
Fatigue
Express feeling of doom
Pericardial temponade
Muffled heart tones ,elevated neck veins
Tension pneumothorax
Tracheal deviation ,decrease or absent unilateral breath sounds ,and chest
hyperresonance on affected side.

MEDICAL MANAGEMENT
GOAL- To limit further myocardial damage and preserve the healthy
myocardium and to improve the cardiac function by increasing cardiac
contractility ,decreasing ventricular after load or both.
CORRECTION OF UNDERLYING CAUSES
To treat the oxygenation needs of the heart muscle to ensure its continued
ability to pump blood to other organs.
In case of coronary cardiogenic shock ,the patient may require thrombolytic
therapy,a percutaneous coronary intervention (PCI),coronary artery bypass
graft (CABG) surgery ,intra aortic balloon pump therapy ,or some
combination of these treatments.
In case of non coronary cardiogenic shock ,intervention focus on correcting
the underlying cause ,such as replacement of a faulty cardiac valve
,correction of a dysrhythmia ,correction of acidosis and electrolyte
disturbances or treatment of the tension pneumothorax.


INITIATION OF FIRST LINE TREATMENT
Oxygenation -In early stage of shock ,supplemental oxygen is administered
by nasal cannula at a rate of 2 to 6 L/min to achieve an oxygen saturation
exceeding 90%
Pain control If patient experiences chest pain ,IV morphine is
administered for pain relief .
Hemodynamic monitoring It is initiated to assess the patients response to
treatment.
Fluid therapy Appropriate fluid administration is also necessary in
treatment of cardiogenic shock.
Pharmacologic therapy-vasoactive medications are given.
MEDICATIONS DESIRED ACTION IN
SHOCK
DISADVANTAGES
INOTROPIC AGENTS
Dobutamine
Dopamine
Epinephrine
Improve contractility
,increase stroke volume
,increase cardiac output
Increase oxygen demand of
the heart
VASODILATORS
Nitroglycerine
Nitropruside
Reduce preload and after
load ,reduce oxygen
demand of the heart
Cause hypotension
VASOPRESSOR
AGENTS
Nor epinephrine
Dopamine
Vasopressin
Increase blood pressure by
vasoconstriction
Increase after load ;there by
increasing cardiac workload
;compromise perfusion to
skin ,kidneys ,lungs
,gastrointestinal tract
NURSING MANAGEMENT
PREVENTING CARDIOGENIC SHOCK
Identifying at risk patients early ,promoting adequate oxygenation of
the heart muscle and decreasing cardiac workload can prevent
cardiogenic shock.
MONITORING HEMODYNAMIC STATUS
Changes in hemodynamic ,cardiac , and pulmonary status and
laboratory values are documented and reported promptly.
ADMINISTERING MEDICATIONS AND INTRAVENOUS
FLUIDS
The nurse play a critical role in effective administration of IV fluids
and medications.
The nurse must documents and records medications and treatments
that are administered as well as the patients response to treatment.
The nurse must be knowledgeable about the desired effects as well
as the side effects of medications .For ex-it is important to monitor
BP after administering morphine or nitroglycerine.

DISTRIBUTIVE SHOCK
Inadequate perfusion of tissues through mal distribution of blood
flow
Intravascular volume is maldistributed because of alterations in
blood vessels
Cardiac pump and blood volume are normal but blood is not
reaching the tissues
ETIOLOGIES
Septic shock (most common )
Anaphylactic shock
Neurogenic shock
PATHOPHYSIOLOGY








SEPTIC SHOCK
Septic shock the most common type of circulatory shock ,is caused by
widespread infection.
Risk factors
Immunosuppressant
Extremes of age (<1 yr and >65 yr)
Malnourishment
Chronic illness
Invasive procedures


PATHOPHYSIOLOGY
INJURY OR INFECTION
LOCAL INFLAMMATORY REACTION
RELEASE OF MEDIATORS
SYSTEMIC INFLAMMATORY RESPONSE
DIFFUSE ENDOTHELIAL INJURY ,VASODILATION AND
INCREASED CAPILLARY PERMEABILITY.
PROGRESSIVE VASODILATION AND MALDISTRIBUTION
OF BLOOD FLOW
ORGAN HYPOTENSION
MULTIPLE ORGAN DYSFUNCTION SYNDROME
CLINICAL PRESENTATION
TWO PHASES
Warm shock - early phase
Hyper dynamic
Cold shock late phase
Hypo dynamic response
DECOMPENSATED STATE
EARLY HYPERDYNAMIC STATE COMPENSATION
Pink ,warm, flushed skin
Increased heart rate
Tachypnoea
Massive vasodilatations




CLINICAL MANIFESTATION
LATE HYPODYNAMIC STATE-DECOMPENSATION
Vasoconstriction
Skin is pale & cold
Tachycardia
Change LOC
Decrease CO
Metabolic alkalosis& respiratory acidosis with hypoxemia
MANAGEMENT
Prevention !!!
Find and kill the source of the infection.
Fluid resuscitation
Vasoconstrictors
Inotropic agents
Maximize O2 delivery support
Nutritional support
Comfort and emotional support.
IN SUMMARY, TREATMENT OF SHOCK
Always dont forget your ABC
Identify the patient at high risk for shock
Control or eliminate the cause
Treat cardiac dysrhythmias
Early intervention and always remember the prevention
Prompt recognition and treatment make the difference outcome.
ANAPHYLACTIC SHOCK
A type of distributive shock that results from widespread systemic
allergic reaction to an antigen.
This hypersensitive reaction is LIFE THREATENING.
PATHOPHYSIOLOGY
Antigen exposure
Body stimulated to produce IgE antibodies specific to antigen.
Drugs ,bites,contrast,blood,foods,vaccines.
Reexposure to antigen
IgE binds to mast cells and basophils
Anaphylactic response
Vasodilatation
Increased vascular permeability
Bronchoconstriction
Increased mucus production


CLINICAL PRESENTATION
o Cutaneous manifestations
Urticaria,erythema,pruritis ,angioedema
o Respiratory compromise
Stridor ,wheezing ,bronchorrhea ,respiratory distress
o Circulatory collapse
Tachycardia ,vasodilation ,hypotension.
MANAGEMENT
Early recognition, treat aggressively
Airway support
IV epinephrine (open airways)
Antihistamines
Corticosteriods
Immediate withdrawl of antigen if possible
Prevention
Judicious crystalloid administration
Vasopressor to maintain organ perfusion
Positive inotropes


NEUROGENIC SHOCK
A type of distributive shock that result from the loss or suppression
of sympathetic tone.
CAUSES
Vasodilation in the venous vasculature,decrease venous return to
heart ,decrease cardiac output.
Spinal cord injury
PATHOPHYSIOLOGY

DISRUPTION OF SYMPATHETIC NERVOUS SYSTEM
LOSS OF SYMPATHETIC TONE
VENOUS AND ARTERIAL VASODILATION
DECREASED VENOUS RETURN
DECREASED STROKE VOLUME
DECREASED CARDIAC OUTPUT
DECREASED CELLULAR OXYGEN SUPPLY
IMPAIRED TISSUE PERFUSION
IMPAIRED CELLULAR METABOLISM
ASSESSMENT ,DIAGNOSTIC AND MANAGEMENT
PATIENT ASSESSMENT MEDICAL MANAGEMENT
HYPOTENSION GOALS OF THERAPY ARE TO TREAT OR
REMOVE THE CAUSE & PREVENT
CARDIOVASCULAR INSTABILITY ,&
PROMOTE OPTIMAL TISSUE PERFUSION.
BRADYCARDIA

HYPOTHERMIA

WARM,DRY SKIN

DECREASED CO
FLACCID PARALYSIS BELOW LEVEL OF
THE SPINAL LESION
MANAGEMENT OF NEUROGENIC SHOCK
Hypovolemia treatment with careful fluid replacement for BP <90
mmhg, change in LOC
Observe closely for fluid overload
Vasopressors may be needed.
Hypothermia warming
Avoid large swings in patient body temperature.
Treat hypoxia
Maintain ventilatory support
Observe for bradycardia- major dysrhytmia
Observe for DVT-venous pooling in extremities make patients high
risk>> P.E



MANAGEMENT OF NEUROGENIC SHOCK
Alpha agonist to augment tone if perfusion still inadequate
Dopamine (<10mcg/kg per min)
Ephedrine (12.5-25 mg IV every 3-4 hour)
o Treat bradycardia with atropine 0.5-1 mg doses to maximum 3mg
May need transcutaneous or transvenous pacing temporarily.
THANK YOU